MEDICARE: PEAK PERFORMANCE PT/MD,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	51214	CO

General Provider Information

NPI Number	:	1699164152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEAK PERFORMANCE PT/MD,LLC

Provider Business Mailing Address
First Line	:	540 MESA VISTA CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-2541
Country	:	US
Telephone Number	:	719-237-8241
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 MESA VISTA CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-2541
Country	:	US
Telephone Number	:	719-237-8241
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LARRY BERARDUCCI
Credential	:	M.D.
Telephone Number	:	314-651-2749

Provider Enumeration Date	:	01/21/2015
Last Update Date	:	01/21/2015

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